病歷範本

Admission order


Admit to the service of Dr. ______

Diagnosis(1): (malignant intern, terminal stage)

Diagnosis(2): (consiousness change, #1 related)

Condition: on critical

Vital Sign As ward routine and PRN

Activity: stay BED REST

Allergy: Naso-gastric tube, Foley tube, new paitent, EKG, irrigation, wrods such as " now!" "imediately!"

Diet as tolerated
 
 
 


 
Addmission note
 
#Cheif Complaint:
Sleepy and general maliase for ___ weeks

#Present Illness:
   The __ years old male / female was very healthy before. He / She denied any systemic disease.
   He / She suffered from intern dog life in CGMH since one year ago. There were many naso-gastric tubes, Foely tubes, arterial gas analysis need to be performed and many complaints from either patients or nurses. Also, large number of paper works, daily progression notes and orders were inevitable. Therefore, he / she went to duty room for help.

#Past history:
No DM, HTN or other systemic disease

#Personal history
Allergy: Naso-gastric tube, Foley tube, new paitent, EKG, irrigation, wrods such as " now!" "imediately!"
Smoking: nil
Drinking: sometimes
Betel nut: nil

#Family history:
No familiar symptoms

#Lab data and PE
E3V4M5, drowsy
others are normal

#Impression
1. Malignant intern, terminal stage
2. Consciousness change, related to #1

#Plan
1. Keep bed resting
2. Supportive care
3. MBD in one weeks, if patient want to AAD, let it be
4. Well informed VS, R and nurses not to call